Spring Fourth-Grade Data Collection & Recruitment for Fifth-Grade

Appendix E ECLS-K2011 Spring 4th Grade Special Education Teacher Questionnaires

Spring Fourth-Grade Data Collection & Recruitment for Fifth-Grade

OMB: 1850-0750

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1850-0750 can be found here:

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APPENDIX E
FOURTH-GRADE
SPECIAL EDUCATION TEACHER QUESTIONNAIRES

Early Childhood Longitudinal Study, Kindergarten Class of 2010-11
(ECLS-K:2011)

Spring Fourth-Grade National Data Collection
and Fifth-Grade Recruitment
OMB Clearance Package
#1850-0750 v.16

Draft

Spring 2015
Special Education Teacher
Questionnaire A
Prepared for the U.S. Department of Education
National Center for Education Statistics by:
Westat
Rockville, Maryland
Use a black or blue ball point pen to complete this questionnaire.

RETURN THIS COMPLETED QUESTIONNAIRE IN THE SEALED
TYVEK® ENVELOPE DIRECTLY TO YOUR SCHOOL COORDINATOR
ORAN ECL
S‐
K:
2011STAF
FMEMBER.
DONOTMAI
LTHIS
QUESTIONNAIRE UNLESS YOU ARE ASKED TO DO SO BY STUDY
STAFF AND ARE PROVIDED WITH AN ENVELOPE FOR MAILING.

S_ID

T_ID

According to the Paperwork Reduction Act of 1995, no persons are required
to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this voluntary survey is
1850‐
XXXX.Appr
ov
alex
pi
r
esXX/
XX/
XXXX.Thet
i
mer
equi
r
edt
oc
ompl
et
et
hi
s
survey is estimated to average 15
30 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed,
and complete and review the survey. If you have any comments concerning
the accuracy of the time estimate or suggestions for improving this survey, or
any comments or concerns regarding the status of your individual submission
of this survey, please write to: Early Childhood Longitudinal Study, National
Cent
erf
orEduc
at
i
onSt
at
i
s
t
i
c
s
,1990KSt
r
eet
,N.
W.
,Was
hi
ngt
on,D.
C.20006‐
5574.

The collection of information in this survey is authorized by 20 U.S.
Code, Section 9543. Participation is voluntary. You may skip questions
you do not wish to answer; however, we hope that you will answer as
many questions as you can. Your responses are protected from
di
s
c
l
os
ur
e by f
eder
al s
t
at
ut
e﴾
20 U.
S. Code,Sec
t
i
on 9573﴿
. Al
l
responses that relate to or describe identifiable characteristics of
individuals may be used only for statistical purposes and may not be
disclosed, or used, in identifiable form for any other purpose except as
required by law. Data will be combined to produce statistical reports.
No individual data that links your name, address, telephone number,
or identification number with your responses will be included in the
statistical reports.

Draft

Dear Special Education Teacher/Related Services Provider,
This questionnaire is an important part of a major longitudinal study of children's early
educational experiences beginning with kindergarten and continuing through grade 5. The
Ear
l
yChi
l
dhoodLongi
t
udi
nalSt
udy,Ki
nder
gar
t
enCl
as
sof2010‐
11﴾
ECLS‐
K:
2011﴿is
collecting information from the special education teachers/related service providers of
s
a
mpl
edc
hi
l
dr
enwhohav
eI
ndi
v
i
dual
i
z
edEduc
at
i
onPr
ogr
ams﴾
I
E
Ps
﴿t
oi
nv
es
t
i
gat
et
he
relationship between the children's academic progress and various school, classroom,
teacher, and home characteristics. This questionnaire collects information about your
background and your work in this school with children with disabilities.
Taking part in the study is voluntary. You may stop at any time or choose not to answer a
question you do not want to answer. However, only you can provide this information.
Although we realize you are very busy, we urge you to complete this questionnaire as
completely and accurately as possible. The information you provide is being collected for
research purposes only and will be protected from disclosure to the fullest extent allowable
byl
aw﴾
Educ
at
i
onSc
i
enc
esRef
or
m Ac
tof2002,20U.
S.
C.
§9573﴿
.
I
nf
or
mat
i
onf
r
om mul
t
i
pl
e
individuals will be combined to produce statistical reports; no information that identifies you
will be included in any reports or provided to students, their parents, or other school staff.

THANK YOU VERY MUCH FOR YOUR HELP.

Draft

What is your gender? MARK ONE RESPONSE.
Male
Female

In what year were you born? WRITE IN YEAR BELOW.

1 9
YEAR
3.

Are you Hispanic or Latino? MARK ONE RESPONSE.
Yes
No

Which best describes your race? MARK ONE OR MORE RESPONSES TO INDICATE WHAT YOU
CONSIDER YOURSELF TO BE.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

What is the highest level of education you have completed? MARK ONE RESPONSE.
Did not complete high school
High school diploma or equivalent/GED
Some college or technical or vocational school
As
s
oc
i
a
t
e’
sdegr
ee
Bachelor's degree
Master's degree
Ana
dv
anc
edpr
of
es
s
i
onaldegr
eebey
ondamas
t
er
’
sdegr
ee﴾
f
orex
a
mpl
e,
Ph.
D.
,
MD﴿

Draft

Is this school year the first year you have worked with children in this school? MARK ONE
RESPONSE.
Yes
No

Counting this school year, how many total years have you been working with children receiving
special education or related services in any school, including years in which you worked part
time? WRITE THE NUMBER OF YEARS TO THE NEAREST FULL SCHOOL YEAR. IF THIS IS YOUR FIRST
YEAR, WRITE "1."
Year
﴾
s
﴿

Counting this school year, how many total years have you been working with children in any
school, including years in which you worked part time? This would include other assignments
such as teaching in a regular classroom or otherwise providing services to children. WRITE THE
NUMBER OF YEARS TO THE NEAREST FULL SCHOOL YEAR. IF THIS IS YOUR FIRST YEAR, WRITE "1."
Year
﴾
s
﴿

Draft

Which of the following credentials, licenses, or certificates do you have for working with children
with disabilities? DO NOT INCLUDE ACADEMIC DEGREES, SUCH AS A BACHELOR'S DEGREE, MASTER'S
DEGREE, OR PH.D. MARK YES OR NO ON EACH ROW.
Yes

a. Emergency credential
b. Provisional or temporary credential
c
. Di
s
abi
l
i
t
y‐
s
pec
i
f
i
cc
r
edent
i
alorendor
s
ement
d. Special education credential or endorsement
﴾
f
ormor
et
hanonedi
s
abi
l
i
t
yc
at
egor
y
﴿
e. General education credential
f.

Speech/language therapy state license or certification

g. Physical therapy state license or certification
h. Occupational therapy state license or certification
i.

Social work license or certification

School psychology license or certification

k. Clinical psychology license or certification
l.

Certificate of Clinical Competence

m. Other professional license, credential, or endorsement
﴾
PL
E
ASESPECI
F
Y﴿

10.

Have you taken the exam for National Board for Professional Teaching Standards certification?
MARK ONE RESPONSE.
Not taken
Taken and passed
Taken and have not yet passed
Taken and awaiting test results
Not applicable

Draft

11.

Have you ever taken a college course in the following areas? MARK YES OR NO ON EACH ROW.
Yes
a. Early childhood education
b. Early childhood special education
c. Elementary education
d. Child development
e. E
ngl
i
s
hasaSec
ondL
angua
ge﴾
E
SL
﴿ort
eac
hi
ngEngl
i
s
h
language learners
f.

General special education

g. Learning disabilities
h. Intellectual disability *
i.

Orthopedic impairments

Serious emotional disturbance

k. Deafness and hearing
l.

Blindness and vision

m. Communication disorders
n. Infants and toddlers with disabilities
o. Physical therapy
p. Occupational therapy
q. School psychology
r.

Classroom management

* Including the condition formerly classified as mental retardation

Draft

12.

Have you ever taken a college course that addressed issues related to the following? MARK YES
OR NO ON EACH ROW.
Yes

a. Using published research evidence to identify and select effective
interventions and supports for students
b. Using formal assessment data to inform the choice of READING
interventions and supports for students
c. Using formal assessment data to inform the choice of MATH
interventions and supports for students
d. Using data to inform the choice of behavioral interventions and
supports for students

13.

Which of the following best describes your current position in this school? MARK ONE RESPONSE.
Special education teacher
Special education teacher consultant
General education teacher
Special education classroom aide
Speec
h‐
l
a
nguagepa
t
hol
ogi
s
t
Physical therapist
Physical therapy assistant or aide
Occupational therapist
Occupational therapy assistant or aide
School psychologist
School counselor
School social worker
Ot
her﴾
PL
EASESPECI
F
Y﴿

Draft

14.

How do you classify your main assignment at this school, that is, the activity at which you spend
most of your time during this school year? MARK ONE RESPONSE.
Regul
arf
ul
l
‐
t
i
met
eac
her
/
s
er
v
i
c
epr
ov
i
der
Regul
arpar
t
‐
t
i
met
eac
her
/
s
er
v
i
c
epr
ov
i
der
I
t
i
ner
antt
eac
her
/
s
er
v
i
c
epr
ov
i
der﴾
t
hati
s
,
y
ouras
s
i
gnmentr
equi
r
esy
out
opr
ov
i
de
i
ns
t
r
uc
t
i
on/
r
el
at
eds
er
v
i
c
esatmor
et
hanones
c
hool
﴿
L
ong‐
t
er
ms
ubs
t
i
t
ut
e﴾
t
hati
s
,
y
ouras
s
i
gnmentr
equi
r
est
haty
ouf
i
l
lt
her
ol
eofa
t
eac
heronal
ong‐
t
er
m bas
i
s
,
buty
ouar
es
t
i
l
lc
ons
i
der
edas
ubs
t
i
t
ut
e﴿
Teacher aide
Ot
her﴾
PL
EASESPECI
F
Y﴿

15.

During this school year, where have you worked with children with IEPs? INCLUDE ONLY
CHILDREN WHO ATTEND THIS SCHOOL. MARK YES OR NO ON EACH ROW.
Yes
a. In a general education classroom
b. In a special education classroom
c
.I
nanon‐
c
l
as
s
r
oom s
pac
e﴾
f
orex
a
mpl
e,
of
f
i
c
e,
t
her
apy
r
oom,
s
mal
lwor
ks
pa
c
e,mobi
l
ev
an,
et
c
.
﴿
d.I
nal
oc
at
i
onout
s
i
deoft
hes
c
hool
s
et
t
i
ng﴾
f
orex
ampl
e,
ac
hi
l
d'
shome,
apr
i
v
at
ec
l
i
ni
c
,
et
c
.
﴿
e. Ot
her﴾
PL
EASESPE
CI
F
Y﴿

Draft

16.

Please indicate the extent to which you agree or disagree with each of the following statements.
MARK ONE RESPONSE ON EACH ROW.
Strongly
disagree

Disagree

Neither
disagree
nor agree

Agree

Strongly
agree

a. I really enjoy my present job.
b. I am certain I am making a
difference in the lives of the
children I work with.
c. If I could start over, I would
choose this career again.
d. I am satisfied with my class
size/caseload.

17.

During the school year, how many children with IEPs have you worked with or provided services
for, on average, each week?﴾
I
nc
l
udec
hi
l
dr
enyouwor
kwi
t
hdi
r
ec
t
l
y,aswel
lasc
hi
l
dr
enf
orwhom
you consult with the general education teacher and/or another special education teacher/service
pr
ovi
der
.
﴿MARK ONE RESPONSE.
1‐
10
11‐
20
21‐
40
More than 40
Don't know

18.

Date questionnaire completed:

2 0 1 5
MONTH

DAY

YEAR

THANK YOU FOR YOUR COOPERATION!

Draft

For Office Use Only
Comp
Ref

Draft

Spring 2015
Special Education Teacher
Questionnaire B
Child Level
Prepared for the U.S. Department of Education
National Center for Education Statistics by:
Westat
Rockville, Maryland
Use a black or blue ball point pen to complete this questionnaire.

S_ID
C_ID

T_ID

According to the Paperwork Reduction Act of 1995, no persons are required
to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this voluntary survey is
1850‐
XXXX.
Appr
ovalex
pi
r
esXX/
XX/
XXXX.Thet
i
mer
equi
r
edt
oc
ompl
et
et
hi
s
survey is estimated to average 15
20 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed,
and complete and review the survey. If you have any comments concerning
the accuracy of the time estimate or suggestions for improving this survey, or
any comments or concerns regarding the status of your individual submission
of this survey, please write to: Early Childhood Longitudinal Study, National
Ce
nt
erf
orEduc
at
i
onSt
at
i
s
t
i
c
s
,1990KSt
r
eet
,N.
W.
,Was
hi
ngt
on,D.
C.20006‐
5574.

Draft

Dear Special Education Teacher/Related Services Provider,
This questionnaire is an important part of a major longitudinal study of children's early
educational experiences beginning with kindergarten and continuing through grade 5. The
Ear
l
yChi
l
dhoodLongi
t
udi
nalSt
udy,Ki
nder
gar
t
enCl
as
sof2010‐
11﴾
ECLS‐
K:
2011﴿is
collecting information from the special education teachers/related service providers of
s
a
mpl
edc
hi
l
dr
enwhohav
eI
ndi
v
i
dual
i
z
edEduc
at
i
onPr
ogr
ams﴾
I
E
Ps
﴿
.
Wear
egat
her
i
ng
information from these children's regular classroom teachers as well. Our purpose is to
investigate the relationship between the children's academic progress and various school,
classroom, teacher, and home characteristics. This questionnaire collects information on the
special education/related services received by the child identified on the cover of this
questionnaire.
Taking part in the study is voluntary. You may stop at any time or choose not to answer a
question you do not want to answer. However, only you can provide this information.
Although we realize you are very busy, we urge you to complete this questionnaire as
completely and accurately as possible. You may find at least some of the information we are
asking for in the child's IEP. All information you provide is being collected for research
purposes only and will be protected from disclosure to the fullest extent allowable by law
﴾
Educ
at
i
onSc
i
enc
esRef
or
m Ac
tof2002,
20U.
S.
C.
§9573﴿
.
I
nf
or
mat
i
onf
r
om mul
t
i
pl
e
individuals will be combined to produce statistical reports; no information that identifies you
will be included in any reports or provided to students, their parents, or other school staff.

THANK YOU VERY MUCH FOR YOUR HELP.

Draft

Is this child currently receiving gifted/talented services through an IEP, or has the child received
such services during this school year? MARK ONE RESPONSE.
Yes
No

Is this child currently receiving special education services through an IEP due to a disability or
has the child received such services during this school year? MARK ONE RESPONSE.
Yes
SKI
PTO Q 34﴿
No ﴾

In what capacity or capacities do you teach or provide services to this child? MARK YES OR NO
ON EACH ROW.
Yes
No
a. Provide instruction directly to the child
b. Provide related services directly to the child
c.

Provide consultation services directly to the child

d.Pr
ov
i
dei
ndi
r
ec
tc
ons
ul
t
at
i
ons
er
v
i
c
es﴾
f
orex
ampl
e,
c
ons
ul
t
a
t
i
on
t
ot
hec
hi
l
d'
st
eac
her
﴿
e. Provide case management
f
. Ot
her﴾
PL
EASESPECI
F
Y﴿

When was this child first determined eligible for special education or related services? MARK
ONE RESPONSE.
Before kindergarten
During kindergarten
During first grade
During second grade
During third grade
During fourth grade
Ot
her﴾
PL
EASESPECI
F
Y﴿

Don't know

Draft

Is this the first school year that the child has been receiving special education services? MARK
ONE RESPONSE.
Yes ﴾
SKI
PTO Q 10﴿
No

When did this child first start receiving special education or related services? MARK ONE
RESPONSE.
Before kindergarten
During kindergarten
During first grade
During second grade
During third grade
Ot
her﴾
PL
EASESPECI
F
Y﴿

Don't know

To what extent were you involved in planning the transition from last year's special education
program to this year's special education program for this child? MARK ONE RESPONSE.
Not at all
Somewhat
Extensively

Towhatext
entdi
dyouc
ommuni
c
at
ewi
t
ht
heper
s
on﴾
s
﴿whopr
ovi
deds
pec
i
aleduc
at
i
onf
or
this child last year? MARK ONE RESPONSE.
Not at all
Somewhat
Extensively
I provided special education for this child last year.

Draft

Have you reviewed this child's records related to special education services provided before
this school year? MARK ONE RESPONSE.
Yes
No, I don't have access to the records.
No, I have access to the records, but have not reviewed them.
No, I provided special education to this child last year.

10.

What is this child's primary disability as identified on the child's IEP? PLEASE SELECT THE
CATEGORY BELOW INTO WHICH THE CHILD'S PRIMARY DISABILITY FITS BEST. MARK ONE RESPONSE.
Speech or language impairments
Specific learning disabilities
Emotional disturbance
Intellectual disability *
Developmental delay
Vi
s
uali
mpai
r
ment
s﴾
i
nc
l
udi
ngbl
i
ndnes
s
﴿
Hear
i
ngi
mpai
r
ment
s﴾
i
nc
l
udi
ngdeaf
nes
s
﴿
Orthopedic impairments
Other health impairments
Autism
Traumatic brain injury
Deaf
‐
bl
i
ndnes
s
Mul
t
i
pl
edi
s
abi
l
i
t
i
es﴾
c
hi
l
dr
eni
nc
l
udedi
nt
hi
sc
at
egor
ys
houl
dbet
hos
ewhohav
emor
et
han
onepr
i
mar
ydi
s
a
bi
l
i
t
ywhi
c
hdonoti
nc
l
udedeaf
‐
bl
i
ndnes
sordev
el
opment
aldel
ay
﴿
No classification is given

* Including the condition formerly classified as mental retardation

Draft

THE REST OF THE ITEMS IN THIS QUESTIONNAIRE REFER TO THIS CHILD'S SPECIAL EDUCATION
EXPERIENCE DURING THE CURRENT SCHOOL YEAR.

11.

During this school year, for which of the following disabilities has this child received special
education or related services, whether for the child's primary disability or another of his/her
disabilities? MARK YES OR NO ON EACH ROW.
Yes

a. Speech or language impairments
b. Specific learning disabilities
c. Emotional disturbance
d. Intellectual disability *
e. Developmental delay
f.

Vi
s
uali
mpai
r
ment
s﴾
i
nc
l
udi
ngbl
i
ndnes
s
﴿

g.Hear
i
ngi
mpai
r
ment
s﴾
i
nc
l
udi
ngdeaf
nes
s
﴿
h. Orthopedic impairments
i.

Other health impairments

Autism

k. Traumatic brain injury
l
. Dea
f
‐
bl
i
ndnes
s
m.Mul
t
i
pl
edi
s
abi
l
i
t
i
es﴾
c
hi
l
dr
eni
nc
l
udedi
nt
hi
sc
at
egor
ys
houl
d
be those who have more than one primary disability which do
noti
nc
l
udedeaf
‐
bl
i
ndnes
sordev
el
opment
a
ldel
a
y
﴿
n. No classification given

12.

During this school year, has this child received any special education or related services
bec
aus
eofadi
agnos
edAt
t
ent
i
onDef
i
c
i
tDi
s
or
der﴾
ADD﴿orAt
t
ent
i
onDef
i
c
i
tHyper
ac
t
i
vi
t
y
Di
s
or
der﴾
ADHD﴿
?MARK ONE RESPONSE.
Yes
No

* Including the condition formerly classified as mental retardation

Draft

13.

Dur
i
ngt
hi
ss
c
hoolyear
,whi
c
hoft
hef
ol
l
owi
ngdes
c
r
i
be﴾
s
﴿t
heI
EPgoal
sf
ort
hi
sc
hi
l
d?MARK
YES OR NO ON EACH ROW.
Yes

Academics
a.

Reading

Mathematics

Language Arts

Science

Speech and language
e.

Auditory processing

Listening comprehension

Oral expression

Voice/speech articulation

Language pragmatics

Social skills

General appropriateness of behavior

Social

Life skills
l.

Adapt
i
v
ebehav
i
orors
el
f
‐
hel
ps
k
i
l
l
s

Physical/Mobility
m.

Fine motor skills

Gross motor skills

Orientation and mobility

Ot
her﴾
PL
EASESPECI
F
Y﴿

Other

Draft

14.

During this school year, which of the following related services have been provided through the
school to this child? MARK YES OR NO ON EACH ROW.
Yes
a. Audiology
b. Counseling services
c. Occupational therapy
d. Physical therapy
e. Psychological services
f.

Health services

g. Social work services
h. Special transportation
i.

Speech or language therapy

Orientation services

k. Mobility services
l.

Rehabilitation services

m.Ot
her﴾
PL
E
ASESPECI
F
Y﴿

Draft

15.

During this school year, has this child received any of the following? MARK YES OR NO ON EACH
ROW.
Yes

a. Adaptive physical education
b.As
s
i
s
t
anc
ef
r
om c
l
as
s
r
oom ai
des﴾
f
orex
ampl
e,
t
eac
herai
de,
beha
v
i
or
alas
s
i
s
t
ant
,
s
pec
i
al
educ
at
i
onai
de﴿
c
.I
nt
er
pr
et
erf
ort
hedeaforhar
dofhear
i
ng﴾
or
alors
i
gn﴿
d. Teacher used Braille to provide instruction
e. Child was taught how to use Braille
f.

Teacher used American Sign Language to provide instruction

g. Child was taught how to use American Sign Language
h. Teacher used Manual English to provide instruction
i.

Child was taught how to use Manual English

Teacher used Cued Speech to provide instruction

k. Child was taught how to use Cued Speech
l.

Mental health services, personal/group counseling, therapy, or
psychiatric care provided to the child

m. Tutoring/remediation from special education teacher
n. Training, counseling, and other supports/services provided to
this child's family

16.

During this school year, has this child's primary placement been a general education classroom?
MARK ONE RESPONSE.
Yes
No

Draft

17.

During this school year, approximately how many hours per week of direct special education
andr
el
at
eds
er
vi
c
es﴾
t
hati
s
,s
er
vi
c
epr
ovi
deddi
r
ec
t
l
yt
ot
hec
hi
l
d,f
r
om at
eacheroranot
her
adul
t
﴿hast
hi
sc
hi
l
dr
ec
ei
ved?WRITE NUMBER IN BOX.
Hours per week

18.

Of the hours of direct special education and related services reported above, approximately
how many of those hours per week were the instruction/services provided outside of a general
education classroom but within the school setting? WRITE NUMBER IN BOX.
Hours per week

PLEASE NOTE THE FOLLOWING DEFINITION
THAT IS RELEVANT TO QUESTION 19 BELOW:
Co‐
t
eac
hi
ngis when a general education teacher and a special education service provider share the
teaching responsibility, with the special education service provider providing specialized differentiated
lessons for students with special needs. The two teachers participate in lesson or activity planning
together and work together in the same classroom to instruct both students with and without disabilities.
19.

During this school year, what teaching practices and methods have you and/or other special
education service providers used with this child? MARK ONE RESPONSE ON EACH ROW.
Yes
a
. One‐
on‐
onei
ns
t
r
uc
t
i
on
b.Sma
l
l
‐
gr
oupi
ns
t
r
uc
t
i
on
c
.L
ar
ge‐
gr
oupi
ns
t
r
uc
t
i
on
d.Co‐
t
eac
hi
ng﴾
s
eedef
i
ni
t
i
ona
bov
e﴿
e. Cooperative learning
f.

Peer tutoring

g. Comput
er
‐
bas
edi
ns
t
r
uc
t
i
on
h. Direct instruction
i.

Cognitive strategies

Sel
f
‐
management

k. Behavior management
l.

Instruction received through a sign interpreter

Don't
know

Draft

20.

During this school year, which of the following best describes the curriculum materials used
with this child in the general education classroom? MARK ONE RESPONSE.
General education curriculum materials were used without modification
General education curriculum materials were used with some modifications
General education curriculum materials were used with substantial modifications
Spec
i
al
l
y
‐
des
i
gnedc
ommer
c
i
almat
er
i
al
swer
eus
ed
Tea
c
her
‐
des
i
gnedmat
er
i
a
l
swer
eus
ed
Child not in this setting
Don't know

21.

During this school year, which of the following best describes the curriculum materials used
with this child in the special education classroom/program? MARK ONE RESPONSE.
General education curriculum materials were used without modification
General education curriculum materials were used with some modifications
General education curriculum materials were used with substantial modifications
Spec
i
al
l
y
‐
des
i
gnedc
ommer
c
i
almat
er
i
al
swer
eus
ed
Tea
c
her
‐
des
i
gnedmat
er
i
a
l
swer
eus
ed
Child not in this setting
Don't know

22.

During this school year, has this child had the assistance of a service animal while at school? A
service animal is any guide dog, signal dog, or other dog individually trained to provide assistance to
a
ni
ndi
v
i
dualwi
t
hadi
s
abi
l
i
t
y
.Ser
v
i
c
eani
mal
sc
anbeus
edf
ul
lt
i
meori
n‐
s
c
hoolonl
yaspa
r
tofa
pr
ogr
am s
uc
ha
sani
malas
s
i
s
t
edt
her
apy﴾
AAT﴿
.
Yes, this child has been assisted by his/her own service dog at school
Yes, this child has been assisted by a service dog provided by a school program
No, this child has not been assisted by a service dog at school

Draft

23.

During this school year, which of the following assistive technologies and devices has this child
used? MARK YES OR NO ON EACH ROW.
Yes

Mobility aids
a.

Vans, vehicles

Wheelchair

Walker

White cane

Communication aids
e.

E
l
ec
t
r
oni
cwi
t
hv
oi
c
eout
put﴾
f
orex
ampl
e,
Touc
hTa
l
k
er
﴿

f
.

E
l
ec
t
r
oni
cwi
t
houtv
oi
c
eout
put﴾
f
orex
a
mpl
e,
dev
i
c
ewi
t
h
v
i
s
ua
ldi
s
pl
ayorpr
i
nt
eds
peec
hout
put
﴿

Non‐
el
ec
t
r
oni
c﴾
f
orex
ampl
e,
manualpr
i
nt
i
ngboar
d﴿

Hearing assistance
h.

Hearing aids

FM loops

TTYs/TDDs

Cochlear implants

Rea
l
‐
t
i
mec
apt
i
oni
ng

Visual aids
m.

Braille texts

Electronic Braille devices

Digital texts

Magnifying devices

Cl
os
e‐
c
a
pt
i
onedt
el
ev
i
s
i
on﴾
CCTV﴿

L
ear
ni
ngai
ds﴾
non‐
c
omput
er
﴿
r.

Tape recorder

Calculator

Electronic spelling devices

Draft

23.

﴾
CONTI
NUED﴿Dur
i
ngt
hi
ss
c
hoolyear
,whi
c
hoft
hef
ol
l
owi
ngas
s
i
s
t
i
vet
ec
hnol
ogi
esanddevi
c
es
has this child used? MARK YES OR NO ON EACH ROW.
Computer hardware designed or adapted for children with
di
s
abi
l
i
t
i
es﴾
f
orexampl
e,al
t
er
nat
ekeyboar
ds
,s
wi
t
c
hi
nt
er
f
ac
e﴿
u.

Used solely by individual child

Shared with other children

Yes

Computer software designed for children with disabilities
w.

Reading

Writing

Mathematics

Other assistive technologies or devices
z
.

24.

Ot
her﴾
PL
EASESPECI
F
Y﴿

Does this child have a computer, laptop, or word processing device assigned to him/her for use
full time this school year? MARK ONE RESPONSE.
Yes
No

25.

Dur
i
ngt
hi
ss
c
hoolyear
,onaver
age,how of
t
enhaveyoumetwi
t
hgener
aleduc
at
i
ont
eac
her
﴾
s
﴿
to discuss this child's program or progress? MARK ONE RESPONSE.
Not applicable because I am the child's general education teacher ﴾
SKI
PTO Q27﴿
SKI
PTO Q27﴿
Not applicable to my work with this child ﴾
Every day or several times a week
Once a week or several times a month
Once a month
A few times over the school year
Once during this school year
Never during this school year ﴾
SKI
PTO Q 27﴿

Draft

26.

Onaver
age,how l
ongwer
et
hemeet
i
ngswi
t
ht
hegener
aleduc
at
i
ont
eacher
﴾
s
﴿t
odi
s
c
us
st
hi
s
child's program or progress? MARK ONE RESPONSE.
1 to 15 minutes
16 to 30 minutes
31 to 45 minutes
46 to 60 minutes
More than 60 minutes

27.

During this school year, approximately how often have you communicated with this child's
par
ent
saboutt
hi
sc
hi
l
d'
spr
ogr
am orpr
ogr
es
s﴾
byphone,i
nper
s
on,ori
nwr
i
t
i
ng,i
nc
l
udi
ng
e‐
mai
l
﴿
?MARK ONE RESPONSE.
Every day or several times a week
Once a week or several times a month
Once a month
A few times over the school year
Once during this school year
Never during this school year

28.

During this school year, has this child received formal individual evaluations in any of the
following areas for purposes of developing IEP goals? MARK YES OR NO ON EACH ROW.
Yes
a. Psychological
b. Speech/language
c. Vision
d. Hearing
e. Learning style
f.

Motor skills

g. Academics
h. Ot
her﴾
PL
E
ASESPECI
F
Y﴿

Draft

29.

To what extent is this child expected to achieve the same general education goals as other
children at his/her grade level this school year? MARK ONE RESPONSE.
Child is expected to attain grade level achievement for all of the academic content standards.
Child is expected to attain grade level achievement for some of the academic content
standards.
Child is expected to attain grade level achievement for only a few of the academic content
standards.
Child is not expected to attain grade level achievement for any of the academic content
standards.
There are no academic content standards at this grade level.
Don't know

30.

What percentage of this child's current IEP goals have been met or nearly met at this point in
the school year? MARK ONE RESPONSE.
76 to 100 percent
51 to 75 percent
26 to 50 percent
1 to 25 percent
0 percent

31.

Which of the following best expresses the likelihood that this child will continue to receive
s
omel
evelofs
pec
i
aleduc
at
i
ons
er
vi
c
es﴾
t
hr
oughanI
EP﴿i
nt
henexts
c
hoolyear
?MARK ONE
RESPONSE.
Definitely will continue in special education
Very likely to continue in special education
Rather likely to continue in special education
Rather unlikely to continue in special education
Very unlikely to continue in special education
ont
i
nuei
ns
pec
i
aleduc
a
t
i
on﴾
wi
l
l
bedi
s
mi
s
s
edf
r
om s
er
v
i
c
es
﴿
Definitely will not c

Draft

32.

Dur
i
ngt
hi
ss
c
hoolyear
,t
owhatext
enthast
hi
sc
hi
l
dpar
t
i
c
i
pat
edi
nanygr
ade‐
l
evelas
s
es
s
ment
administered as part of the school's testing program? MARK ONE RESPONSE.
Child did not participate in the school's testing or assessment program. ﴾
SKI
PTO Q 34﴿
Child participated in alternate assessments and no regular assessments. ﴾
SKI
PTO Q 34﴿
Child participated in some alternate assessments and some regular assessments.
Child participated fully in the school's regular testing or assessment program.
There is no testing or assessment program at this grade level. ﴾
SKI
PTOQ34﴿
Don't know ﴾
SKI
PTO Q34﴿

33.

Did this child receive special accommodations to participate in the school's regular testing or
assessment program this school year? MARK ONE RESPONSE.
Yes
No
Don't know

34.

In which grade is this child enrolled? MARK ONE RESPONSE.
Kindergarten
First grade
Second grade
Third grade
Fourth grade
Fifth grade or higher
This child is in an ungraded classroom

35.

Date Questionnaire Completed:

2 0 1 5
MONTH

DAY

YEAR

THANK YOU FOR YOUR COOPERATION!

Draft

For Office Use Only
Comp
Ref

Draft

File Type	application/pdf
Author	nickey_z
File Modified	2014-07-01
File Created	2014-05-16